Teacher Cost Survey

Attachment Y

Teacher Cost Survey

• Safe Dates Evaluation - Lesson 1 Questionnaire

• Safe Dates Evaluation - Lesson 2 Questionnaire

• Safe Dates Evaluation - Lesson 3 Questionnaire

• Safe Dates Evaluation - Lesson 4 Questionnaire

• Safe Dates Evaluation - Lesson 5 Questionnaire

• Safe Dates Evaluation - Lesson 6 Questionnaire

• Safe Dates Evaluation - Lesson 7 Questionnaire

• Safe Dates Evaluation - Lesson 8 Questionnaire

• Safe Dates Evaluation - Lesson 9 Questionnaire

• Safe Dates Evaluation - Poster Contest

• Safe Dates Evaluation – “There’s No Excuse for Dating Abuse” Play

Form Approved

OMB No. 0920-0783

Exp. Date: 06/30/2011

Public Reporting burden of this collection of information is estimated at 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-0783).

SAFE DATES Evaluation – Lesson 1 Questionnaire

Thank you for assisting us with the Safe Dates evaluation. As you prepare for and teach the Safe Dates curriculum, please keep track of all time that you spend on all Safe Dates-related activities. Please record your time after as soon as possible after each lesson. This will also minimize the effort required to complete this questionnaire.

Please complete and submit this material within two school days of completing this lesson. If you have any questions, please contact Thomas Hylands by phone [1-800-334-8571, x6955] or e-mail [[email protected]].

Date: _____/_____/________

A. SCHOOL INFORMATION

1. School name: _________________________________________________________

2. School district: _________________________________________________________

3. Teacher name: _________________________________________________________

B. TEACHER INFORMATION

4. Subject(s) taught: ____________________________________________________

5. Grade(s) taught: _____________

6. Total number of years teaching: ____________

7. Total number of years in this school district: ____________

8. Previous experience teaching any part of Safe Dates prior to this semester: 1 ______ Yes

2 ______ No

9. College degree(s) and major(s): _______________________________________________
   
   _______________________________________________

Your participation is important to us. To show our appreciation, after RTI receives your information for all nine Safe Dates lessons and for the play and poster contest, you will receive an $80 gift card.

C. TIME AND ACTIVITY LOG

In this section, we ask that you record your time spent on each Safe Dates lesson. Instructions and an example are provided below. An activity log for Lesson 1 (“Defining Caring Relationships”) is on the next screen.

INSTRUCTIONS

• We anticipate that you may teach each Safe Dates lesson to multiple classes. Please record your time separately by class and activity (the rows of the table).

• For activities that are difficult to divide between classes (e.g., preparation, photocopying), record your time under “General Safe Date Activities.”

• Record class-specific activities (e.g., instruction) in the appropriate columns.

• All entries in the grid should sum to the total time you spent related to Safe Dates Lesson 1. There should be no double counting or missed time.

• Do not include or record your time spent completing this questionnaire. We are only interested in the time associated with teaching and preparing for the Safe Dates curriculum.

EXAMPLE

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparation (before class)	60 min	0 min	0 min	0 min	0 min			60 min
Instruction (in class)	0 min	50 min	50 min	50 min	50 min			200 min
Wrap-up (after class)	15 min	5 min	0 min	0 min	0 min			20 min
Optional Activities (not included in time above)
Prepare and distribute parent letter/newsletter	30 min	0 min	0 min	0 min	0 min			30 min
Obtain student journals	60 min	0 min	0 min	0 min	0 min			60 min
Administer pre-test (if time not included above)	30 min	20 min	20 min	20 min	20 min			110 min
							Total time	480 min (8 hr 0 m)

TIME AND ACTIVITY LOG

Lesson 1: “Defining Caring Relationships”

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparation (before class)
Instruction (in class)
Wrap-up (after class)
Optional Activities (not included in time above)
Prepare and distribute parent letter/newsletter
Obtain student journals
Administer pre-test (if time not included above)
Other Activities (not included in time above)
Other Safe Dates activities (not included above)
							Total time

10. Did you receive assistance from anyone in preparing for or teaching this lesson?
    1 _____ Yes 2 _____ No
    
    

[If 10=YES, GOTO 10.a]

[If 10=NO, GOTO 11]

1. Please list their job title (e.g., administrative assistant), the activity they assisted with (e.g., photocopying), and estimate the amount of time involved.
   __________________________________________________________________
   __________________________________________________________________

11. If you recorded time for “Other Safe Dates activities” above (last row), please describe the activities here. This may include attending training classes, meetings related to Safe Dates, supplemental activities, etc.
    ______________________________________________________________________
    ______________________________________________________________________
    
    

12. Were any additional materials purchased by the school or by you for this lesson?

1 _____ Yes 2 _____ No

[If 12=YES, GOTO 12.a]

[If 12=NO, GOTO 13]

1. Please estimate the total cost of these materials: ____________________________

2. Please describe briefly: ________________________________________________
   ___________________________________________________________________

D. SAFE DATES ACTIVITIES

Please complete this section after you have taught Lesson 1 to your students.

Date(s) Lesson 1 taught: _____/_____/______

	Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Number of students
Were you able to get through the following items in the Lesson 1 outline? Please write “yes” or “no” for each item.
Optional Pre-Test
Part 1: Introducing the Safe Dates curriculum to students
Part 2: What is dating?
Part 3: Dating bingo
Part 4 (Optional): Caring people and caring relationships
Part 5: How I want to be treated by a dating partner
Part 6: Homework assignment
Part 7: Conclusion

Instructions: For the following questions, please use the scale provided below to indicate the extent to which you agree with the following statements. Circle the number associated with the response that comes closest to your answer. If you ‘don’t know” circle “0”; if the statement does not apply to you, circle “9”, not applicable.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

13. The most important parts of this lesson were implemented as prescribed in the Safe Dates curriculum guide.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

14. I modified some of the lesson content in the course of teaching this Safe Dates lesson.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

15. I made modifications in the activities used to teach this Safe Dates lesson.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

16. I taught this Safe Dates lesson exactly as specified in the Safe Dates curriculum guide.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

17. For “Part 1: Introducing the Safe Dates Curriculum,” did you have ground rules as suggested in the Safe Dates instructor’s manual?
    
    

1 _____ Yes 2 _____ No

18. For “Part 6: Homework Assignment,” did you give students Handout 4: Ways I Want to Treat a Dating Partner to complete in class or as homework?
    
    

1 _____ In class 2 _____ Homework 3 _____ Didn’t get to it at all

Form Approved

OMB No. 0920-0783

Exp. Date: 06/30/2011

SAFE DATES Evaluation – Lesson 2 Questionnaire

Thank you for assisting us with the Safe Dates evaluation. As you prepare for and teach the Safe Dates curriculum, please keep track of all time that you spend on all Safe Dates-related activities. Please record your time after as soon as possible after each lesson. This will also minimize the effort required to complete this questionnaire.

Please complete and submit this material within two school days of completing this lesson. If you have any questions, please contact Thomas Hylands by phone [1-800-334-8571, x6955] or e-mail [[email protected]].

Date: _____/_____/________

Public Reporting burden of this collection of information is estimated at 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-0783).

A. SCHOOL INFORMATION

1. School name: _______________________________________________________

2. Teacher name: _______________________________________________________

Your participation is important to us. To show our appreciation, after RTI receives your information for all nine Safe Dates lessons, the play, and the poster contest, you will receive an $80 gift card.

B. TIME AND ACTIVITY LOG

In this section, we ask that you record your time spent on each Safe Dates lesson. Instructions and an example are provided below. An activity log for Lesson 2 (“Defining Dating Abuse”) is on the next screen.

INSTRUCTIONS

• We anticipate that you may teach each Safe Dates lesson to multiple classes. Please record your time separately by class and activity (the rows of the table).

• For activities that are difficult to divide between classes (e.g., preparation, photocopying), record your time under “General Safe Date Activities.”

• Record class-specific activities (e.g., instruction) in the appropriate columns.

• All entries in the grid should sum to the total time you spent related to Safe Dates Lesson 2. There should be no double counting or missed time.

• Do not include or record your time spent completing this questionnaire. We are only interested in the time associated with teaching and preparing for the Safe Dates curriculum.

EXAMPLE

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparation (before class)	60 min	0 min	0 min	0 min	0 min			60 min
Instruction (in class)	0 min	50 min	50 min	50 min	50 min			200 min
Wrap-up (after class)	15 min	5 min	0 min	0 min	0 min			20 min
							Total time	280 min (4 hr 40 m)

TIME AND ACTIVITY LOG

Lesson 2: “Defining Dating Abuse”

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparation (before class)
Instruction (in class)
Wrap-up (after class)
Other Activities (not included in time reported above)
Other Safe Dates activities (describe below)
							Total time

3. Did you receive assistance from anyone in preparing for or teaching this lesson?
   
   1 _____ Yes 2 _____ No

[If 3=YES, GOTO 3.a]

[If 3=NO, GOTO 4]

1. Please list their job title (e.g., administrative assistant), the activity they assisted with (e.g., photocopying), and estimate the amount of time involved.
   
   

__________________________________________________________________

__________________________________________________________________

4. If you recorded time for “Other Safe Dates activities” above (last row), please describe the activities here. This may include attending training classes, meetings related to Safe Dates, supplemental activities, etc.
   
   ______________________________________________________________________
   
   ______________________________________________________________________
   
   ______________________________________________________________________
   
   

5. Were any additional materials purchased by the school or by you for this lesson?

1 _____ Yes 2 _____ No

[If 5=YES, GOTO 5.a]

[If 5=NO, GOTO 6]

1. Please estimate the total cost of these materials: ____________________________

2. Please describe briefly: ________________________________________________
   
   ___________________________________________________________________

C. SAFE DATES ACTIVITIES

Please complete this section after you have taught Lesson 2 to your students.

Date(s) Lesson 2 taught: _____/_____/_______

	Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Number of students
Were you able to get through the following items in the Lesson 2 outline? Please write “yes” or “no” for each item.
Part 1: Ground rules and homework
Part 2: Identifying harmful behaviors
Part 3: What is abuse?
Part 4: Defining abusive dating relationships
Part 5: Facts about dating abuse
Part 6: Conclusion

Instructions: For the following questions, please use the scale provided below to indicate the extent to which you agree with the following statements. Circle the number associated with the response that comes closest to your answer. If you ‘don’t know’ circle “0”; if the statement does not apply to you, circle “9”, not applicable.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

6. The most important parts of this lesson were implemented as prescribed in the Safe Dates curriculum guide.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

7. I modified some of the lesson content in the course of teaching this Safe Dates lesson.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

8. I made modifications in the activities used to teach this Safe Dates lesson.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

9. I taught this Safe Dates lesson exactly as specified in the Safe Dates curriculum guide.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

Form Approved

OMB No. 0920-0783

Exp. Date: 06/30/2011

SAFE DATES Evaluation – Lesson 3 Questionnaire

Thank you for assisting us with the Safe Dates evaluation. As you prepare for and teach the Safe Dates curriculum, please keep track of all time that you spend on all Safe Dates-related activities. Please record your time after as soon as possible after each lesson. This will also minimize the effort required to complete this questionnaire.

Please complete and submit this material within two school days of completing this lesson. If you have any questions, please contact Thomas Hylands by phone [1-800-334-8571, x6955] or e-mail [[email protected]].

Date: _____/_____/________

Public Reporting burden of this collection of information is estimated at 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-0783).

A. SCHOOL INFORMATION

1. School name: _______________________________________________________

2. Teacher name: _______________________________________________________

Your participation is important to us. To show our appreciation, after RTI receives your information for all nine Safe Dates lessons, the play, and the poster contest, you will receive an $80 gift card.

B. TIME AND ACTIVITY LOG

In this section, we ask that you record your time spent on each Safe Dates lesson. Instructions and an example are provided below. An activity log for Lesson 3 (“Why Do People Abuse?”) is on the next screen.

INSTRUCTIONS

• We anticipate that you may teach each Safe Dates lesson to multiple classes. Please record your time separately by class and activity (the rows of the table).

• For activities that are difficult to divide between classes (e.g., preparation, photocopying), record your time under “General Safe Date Activities.”

• Record class-specific activities (e.g., instruction) in the appropriate columns.

• All entries in the grid should sum to the total time you spent related to Safe Dates Lesson 3. There should be no double counting or missed time.

• Do not include or record your time spent completing this questionnaire. We are only interested in the time associated with teaching and preparing for the Safe Dates curriculum.

EXAMPLE

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparation (before class)	60 min	0 min	0 min	0 min	0 min			60 min
Instruction (in class)	0 min	50 min	50 min	50 min	50 min			200 min
Wrap-up (after class)	15 min	5 min	0 min	0 min	0 min			20 min
							Total time	280 min (4 hr 40 m)

TIME AND ACTIVITY LOG

Lesson 3: “Why Do People Abuse?”

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparation (before class)
Instruction (in class)
Wrap-up (after class)
Other Activities (not included in time reported above)
Other Safe Dates activities (describe below)
							Total time

3. Did you receive assistance from anyone in preparing for or teaching this lesson?
   
   1 _____ Yes 2 _____ No

[If 3=YES, GOTO 3.a]

[If 3=NO, GOTO 4]

1. Please list their job title (e.g., administrative assistant), the activity they assisted with (e.g., photocopying), and estimate the amount of time involved.
   
   

__________________________________________________________________

__________________________________________________________________

4. If you recorded time for “Other Safe Dates activities” above (last row), please describe the activities here. This may include attending training classes, meetings related to Safe Dates, supplemental activities, etc.
   
   ______________________________________________________________________
   
   ______________________________________________________________________
   
   ______________________________________________________________________

5. Were any additional materials purchased by the school or by you for this lesson?

1 _____ Yes 2 _____ No

[If 5=YES, GOTO 5.a]

[If 5=NO, GOTO 6]

a. Please estimate the total cost of these materials: ____________________________

b. Please describe briefly: ________________________________________________

___________________________________________________________________

C. SAFE DATES ACTIVITIES

Please complete this section after you have taught Lesson 3 to your students.

Date(s) Lesson 3 taught: _____/_____/______

	Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Number of students
Were you able to get through the following items in the Lesson 3 outline? Please write “yes” or “no” for each item.
Part 1: People abuse to control and manipulate someone
Part 2: Other reasons for abuse
Part 3: Consequences of dating abuse
Part 4: Warning signs of abuse
Part 5: Conclusion

6. Did you post or ask students to post the list of “red flags” in your hallways, bathrooms, or other school locations? (optional activity)

1 _____ Yes 2 _____ No

Instructions: For the following questions, please use the scale provided below to indicate the extent to which you agree with the following statements. Circle the number associated with the response that comes closest to your answer. If you ‘don’t know’ circle “0”; if the statement does not apply to you, circle “9”, not applicable.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

7. The most important parts of this lesson were implemented as prescribed in the Safe Dates curriculum guide.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

8. I modified some of the lesson content in the course of teaching this Safe Dates lesson.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

9. I made modifications in the activities used to teach this Safe Dates lesson.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

10. I taught this Safe Dates lesson exactly as specified in the Safe Dates curriculum guide.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

Form Approved

OMB No. 0920-0783

Exp. Date: 06/30/2011

SAFE DATES Evaluation – Lesson 4 Questionnaire

Thank you for assisting us with the Safe Dates evaluation. As you prepare for and teach the Safe Dates curriculum, please keep track of all time that you spend on all Safe Dates-related activities. Please record your time after as soon as possible after each lesson. This will also minimize the effort required to complete this questionnaire.

Please complete and submit this material within two school days of completing this lesson. If you have any questions, please contact Thomas Hylands by phone [1-800-334-8571, x6955] or e-mail [[email protected]].

Date: _____/_____/________

Public Reporting burden of this collection of information is estimated at 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-0783).

A. SCHOOL INFORMATION

1. School name: _______________________________________________________

2. Teacher name: _______________________________________________________

Your participation is important to us. To show our appreciation, after RTI receives your information for all nine Safe Dates lessons, the play, and the poster session, you will receive an $80 gift card.

B. TIME AND ACTIVITY LOG

In this section, we ask that you record your time spent on each Safe Dates lesson. Instructions and an example are provided below. An activity log for Lesson 4 (“How to Help Friends”) is on the next screen.

INSTRUCTIONS

• We anticipate that you may teach each Safe Dates lesson to multiple classes. Please record your time separately by class and activity (the rows of the table).

• For activities that are difficult to divide between classes (e.g., preparation, photocopying), record your time under “General Safe Date Activities.”

• Record class-specific activities (e.g., instruction) in the appropriate columns.

• All entries in the grid should sum to the total time you spent related to Safe Dates Lesson 4. There should be no double counting or missed time.

• Do not include or record your time spent completing this questionnaire. We are only interested in the time associated with teaching and preparing for the Safe Dates curriculum.

EXAMPLE

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparation (before class)	60 min	0 min	0 min	0 min	0 min			60 min
Instruction (in class)	0 min	50 min	50 min	50 min	50 min			200 min
Wrap-up (after class)	15 min	5 min	0 min	0 min	0 min			20 min
							Total time	280 min (4 hr 40 m)

TIME AND ACTIVITY LOG

Lesson 4: “How to Help Friends”

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparation (before class)
Instruction (in class)
Wrap-up (after class)
Other Activities (not included in time reported above)
Other Safe Dates activities (describe below)
							Total time

3. Did you receive assistance from anyone in preparing for or teaching this lesson?
   
   1 _____ Yes 2 _____ No

[If 3=YES, GOTO 3.a]

[If 3=NO, GOTO 4]

a. Please list their job title (e.g., administrative assistant), the activity they assisted with (e.g., photocopying), and estimate the amount of time involved.

__________________________________________________________________

__________________________________________________________________

4. If you recorded time for “Other Safe Dates activities” above (last row), please describe the activities here. This may include attending training classes, meetings related to Safe Dates, supplemental activities, etc.
   
   ______________________________________________________________________
   
   ______________________________________________________________________
   
   ______________________________________________________________________

5. Were any additional materials purchased by the school or by you for this lesson?

1 _____ Yes 2 _____ No

[If 5=YES, GOTO 5.a]

[If 5=NO, GOTO 6]

a. Please estimate the total cost of these materials: ____________________________

b. Please describe briefly: ________________________________________________

___________________________________________________________________

C. SAFE DATES ACTIVITIES

Please complete this section after you have taught Lesson 4 to your students.

Date(s) Lesson 4 taught: _____/_____/_______

	Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Number of students
Were you able to get through the following items in the Lesson 4 outline? Please write “yes” or “no” for each item.
Part 1: Why don’t people just leave?
Part 2: Why is it hard to get help?
Part 3: How to help a friend
Part 4: Community resources
Part 5: Conclusion

Instructions: For the following questions, please use the scale provided below to indicate the extent to which you agree with the following statements. Circle the number associated with the response that comes closest to your answer. If you ‘don’t know’ circle “0”; if the statement does not apply to you, circle “9”, not applicable.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

6. The most important parts of this lesson were implemented as prescribed in the Safe Dates curriculum guide.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

7. I modified some of the lesson content in the course of teaching this Safe Dates lesson.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

8. I made modifications in the activities used to teach this Safe Dates lesson.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

9. I taught this Safe Dates lesson exactly as specified in the Safe Dates curriculum guide.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

10. For “Part 3: How to Help a Friend,” what kinds of changes, if any, did you make to facilitate discussion about the Friends Wheel?

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Form Approved

OMB No. 0920-0783

Exp. Date: 06/30/2011

SAFE DATES Evaluation – Lesson 5 Questionnaire

Thank you for assisting us with the Safe Dates evaluation. As you prepare for and teach the Safe Dates curriculum, please keep track of all time that you spend on all Safe Dates-related activities. Please record your time after as soon as possible after each lesson. This will also minimize the effort required to complete this questionnaire.

Please complete and submit this material within two school days of completing this lesson. If you have any questions, please contact Thomas Hylands by phone [1-800-334-8571, x6955] or e-mail [[email protected]].

Date: _____/_____/________

Public Reporting burden of this collection of information is estimated at 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-0783).

Your participation is important to us. To show our appreciation, after RTI receives your information for all nine Safe Dates lessons, the play, and the poster contest, you will receive an $80 gift card.

A. TIME AND ACTIVITY LOG

In this section, we ask that you record your time spent on each Safe Dates lesson. Instructions and an example are provided below. An activity log for Lesson 5 (“Helping Friends”) is on the next screen.

INSTRUCTIONS

• We anticipate that you may teach each Safe Dates lesson to multiple classes. Please record your time separately by class and activity (the rows of the table).

• For activities that are difficult to divide between classes (e.g., preparation, photocopying), record your time under “General Safe Date Activities.”

• Record class-specific activities (e.g., instruction) in the appropriate columns.

• All entries in the grid should sum to the total time you spent related to Safe Dates Lesson 5. There should be no double counting or missed time.

• Do not include or record your time spent completing this questionnaire. We are only interested in the time associated with teaching and preparing for the Safe Dates curriculum.

EXAMPLE

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparation (before class)	60 min	0 min	0 min	0 min	0 min			60 min
Instruction (in class)	0 min	50 min	50 min	50 min	50 min			200 min
Wrap-up (after class)	15 min	5 min	0 min	0 min	0 min			20 min
							Total time	280 min (4 hr 40 m)

TIME AND ACTIVITY LOG

Lesson 5: “Helping Friends”

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparation (before class)
Instruction (in class)
Wrap-up (after class)
Other Activities (not included in time reported above)
Other Safe Dates activities (describe below)
							Total time

1. Did you receive assistance from anyone in preparing for or teaching this lesson?
   
   1 _____ Yes 2 _____ No

[If 1=YES, GOTO 2]

[If 1=NO, GOTO 3]

2. Please list their job title (e.g., administrative assistant), the activity they assisted with (e.g., photocopying), and estimate the amount of time involved.

__________________________________________________________________

__________________________________________________________________

3. If you recorded time for “Other Safe Dates activities” above (last row), please describe the activities here. This may include attending training classes, meetings related to Safe Dates, supplemental activities, etc.
______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

4. Were any additional materials purchased by the school or by you for this lesson?

1 _____ Yes 2 _____ No

[If 4=YES, GOTO 5.a]

[If 4=NO, GOTO 6]

5a. Please estimate the total cost of these materials: ____________________________

5b. Please describe briefly: ________________________________________________

___________________________________________________________________

B. SAFE DATES ACTIVITIES

Please complete this section after you have taught Lesson 5 to your students.

Date Lesson 5 taught: _____/_____/_______

	Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Number of students
Were you able to get through the following items in the Lesson 5 outline? Please write “yes” or “no” for each item.
Part 1: Greg’s story
Part 2: Michele’s story
Part 3: Being a friend
Part 4: Conclusion

Instructions: For the following questions, please use the scale provided below to indicate the extent to which you agree with the following statements. Circle the number associated with the response that comes closest to your answer. If you ‘don’t know” circle “0”; if the statement does not apply to you, circle “9”, not applicable.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

6. The most important parts of this lesson were implemented as prescribed in the Safe Dates curriculum guide.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

7. I modified some of the lesson content in the course of teaching this Safe Dates lesson.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

8. I made modifications in the activities used to teach this Safe Dates lesson.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

9. I taught this Safe Dates lesson exactly as specified in the Safe Dates curriculum guide.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

9. For “Part 3: Being a Friend,” did you do step 3 as it was described in the curriculum (with the two circles of students)?

1 _____ Yes 2 _____ No

[If =YES, GOTO 12]

[If 10=NO, GOTO 11]

9. Briefly describe the changes you made.
   
   

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

We are seeking your first impressions and reactions.

Please provide responses based on what you know or what you think. Feel free to use the ‘don’t know’ option as needed. There are no “right” or “wrong” answers.

We recommend that you work quickly without puzzling or worrying about individual questions. We are aware that some questions may appear to be repetitive but it is necessary to ask a variety of questions to obtain reliable and accurate information about the topics addressed in the questionnaire.

Privacy:

All answers you provide will be kept private. Findings will be summarized in aggregated form to protect the identity of participating individuals and schools.

Background Information: Please provide the following information so that we a) can match your answers to this survey with those on follow-up surveys b) describe study participants, and c) group responses according to title, school, etc. The information you provide will be kept private.

12. Your title: _______________________

12a. Duration of a health class period: ______ minutes.

	13.	Which of the following options best describes how the Safe Dates (SD) Program is being incorporated into your school's broader health or prevention curriculum? ____ Independent course in the health or prevention curriculum ____ Discrete module within a course in the health or prevention curriculum ____ Safe Dates lessons are being interspersed among other topics the curriculum ____ Other (please explain: ______________________________________________)
	14. 15.	The Safe Dates curriculum is designed to be taught in the form of nine, 50-minute lessons. Please indicate the actual kickoff date and a likely completion date for teaching the 9- session Safe Dates curriculum. The actual kick-off date for the Safe Dates Curriculum was (mm/dd/yy): _______________ The estimated completion date for the Safe Dates Curriculum is (mm/dd/yy): ____________
	16.	Thinking back to the first five lessons in the Safe Dates curriculum, for how many of those lessons did you follow the curriculum guide to the letter? ____ None of the first five Safe Dates lessons ____ 1 of the first 5 ____ 2 of the first 5 ____ 3 of the first 5 ____ 4 of the first 5 ____ All five of the first 5 Safe Dates lessons

Instructions: Using the scale provided below, please indicate the extent to which you agree with each of the following statements. Enter the number that most closely reflects your response in the space provided next to each phrase. Enter “0” if you don’t know or “9” if the question does not apply to you or your school.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

The Safe Dates curriculum must be implemented in a precise and prescribed manner in order to be effective.

_______

In my view, formal training is needed in order for teachers to do a good job implementing the Safe Dates curriculum.

_______

The Safe Dates curriculum is complicated to implement correctly.

_______

I have implemented the Safe Dates curriculum exactly as has been prescribed by its developers.

_______

I followed the curriculum guide to the letter in the process of teaching the Safe Dates program.

_______

The only reason that I am teaching the Safe Dates curriculum is because I have to.

_______

I added classroom activities to one or more Safe Dates lesson.

_______

The district office has been very supportive of this school's efforts to implement the Safe Dates curriculum.

_______

It is not clear who is leading this school's efforts to implement the Safe Dates curriculum.

_______

If needed, teachers have access to experts who know how to implement the Safe Dates curriculum.

_______

Clear and specific goals have been established pertaining to the implementation of the Safe Dates curriculum during the course of the study.

_______

School administrators adequately address the concerns of teachers charged with implementing the Safe Dates curriculum.

_______

This school has the resources necessary to support the ongoing implementation of Safe Dates.

_______

Teachers involved in implementing the Safe Dates curriculum get recognition from their supervisors.

_______

The administration monitors how things are going with the implementation of the Safe Dates curriculum.

_______

Teachers are not speaking up although they harbor serious doubts about the effectiveness of Safe Dates.

_______

Overall, students seem to like the Safe Dates curriculum.

_______

Instructions: Using the scale provided below, please indicate the extent to which you agree with each of the following statements. Enter the number that most closely reflects your response in the space provided next to each phrase. Enter “0” if you don’t know or “9” if the question does not apply to you or your school

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

Most students seemed interested in the material presented in the Safe Dates program.

_______

Adaptations can be made in how the Safe Dates curriculum is implemented without jeopardizing its effectiveness.

_______

The curriculum guide is sufficient to prepare the average teacher to do a good job implementing the Safe Dates curriculum.

_______

It is easy to prepare teachers to implement the Safe Dates curriculum as recommended by experts.

_______

I have made modifications in the Safe Dates curriculum while teaching one or more of the first five lessons.

_______

I rarely followed the curriculum guide in the process of teaching Safe Dates lessons.

_______

I am teaching the Safe Dates curriculum because I want to.

_______

I added material to one or more of the first five Safe Dates lessons.

_______

The school board has been very supportive of this school's efforts to implement the Safe Dates (prevention) curriculum.

_______

There was not enough time to adequately plan for the implementation of the Safe Dates curriculum at this school.

_______

Training is available to any teacher who needs guidance in order to implement Safe Dates as prescribed by experts.

_______

The school administration has clearly communicated its expectations pertaining to the implementation of the Safe Dates curriculum during the course of the study.

_______

School administrators insure that everything necessary for the implementation of Safe Dates is made available to teachers.

_______

The school has the manpower necessary to support the ongoing implementation of Safe Dates.

_______

Teachers are given positive feedback for contributing to the implementation of the Safe Dates program.

_______

The administration holds meetings with teachers to review how the implementation of Safe Dates is going.

_______

Teachers are encouraged to speak openly about the strengths and weaknesses of the Safe Dates curriculum from the Prevention Coordinator and/or teachers.

_______

The Prevention Coordinator seems to like the Safe Dates curriculum.

_______

Overall, students seemed engaged in Safe Dates classroom activities.

_______

Some components of the Safe Dates curriculum have to be implemented as prescribed but others do not.

_______

In my view, the average teacher is likely to need follow-up training or coaching in order to do a good job implementing the Safe Dates curriculum.

_______

There are one or more reasons why it’s difficult for teachers to implement the Safe Dates curriculum at this school.

_______

I have implemented the most important elements of the Safe Dates curriculum as it has been prescribed by program developers.

_______

Instructions: Using the scale provided below, please indicate the extent to which you agree with each of the following statements. Enter the number that most closely reflects your response in the space provided next to each phrase. Enter “0” if you don’t know or “9” if the question does not apply to you or your school.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

I taught the material exactly as specified in the Safe Dates curriculum guide.

_______

I made modifications in the course of teaching the Safe Dates curriculum.

_______

Parents generally have been very supportive of this school's efforts to implement the Safe Dates curriculum.

_______

The implementation of the Safe Dates curriculum has not been well coordinated at this school.

_______

If questions arise about implementing the Safe Dates program, teachers have ready access to needed information.

_______

Teachers who are responsible for implementing the Safe Dates curriculum have a clear understanding of their roles and responsibilities.

_______

Teachers responsible for implementing Safe Dates believe they are given the tools and resources they need to do so effectively.

_______

We do not have the resources necessary to implement the Safe Dates program on a long-term basis.

_______

Teachers responsible for implementing the Safe Dates program know their efforts are appreciated by this school.

_______

The administration gets regular progress reports about the implementation of the Safe Dates curriculum.

_______

Often teachers feel pressured not to “rock the boat” by speaking their minds about the pros and cons of the Safe Dates curriculum.

_______

School administrators appear to like the Safe Dates curriculum.

_______

Students frequently asked questions during Safe Dates classes.

_______

Teaching Safe Dates exactly as it was developed by experts is critical to getting expected results.

_______

After reviewing the curriculum guide, the average teacher will be well-equipped to do a good job implementing the Safe Dates curriculum.

_______

It is easy to implement the Safe Dates curriculum correctly on a consistent basis.

_______

The way I am implementing Safe Dates departs significantly from what is prescribed by its developers.

_______

I made modifications in the activities used to teach the Safe Dates curriculum.

_______

The School principal has been very supportive of this school's efforts to implement the Safe Dates curriculum.

_______

The individual in charge of leading the effort to implement the Safes Dates curriculum lacked some important skills.

_______

Technical assistance is available to teachers who are responsible for teaching Safe Dates.

_______

School administrators do a good job removing barriers that interfere with teaching the Safe Dates curriculum exactly as prescribed.

_______

This school has the resources necessary to support the initial implementation of Safe Dates.

_______

Top administrators provide encouragement to teachers involved in implementing the Safe Dates program.

_______

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

Instructions: Using the scale provided below, please indicate the extent to which you agree with each of the following statements. Enter the number that most closely reflects your response in the space provided next to each phrase. Enter “0” if you don’t know or “9” if the question does not apply to you or

your school.

The administration pays close attention to the progress being made related to implementing the Safe Dates program.

_______

Overall, parents seem to like the Safe Dates curriculum.

_______

Student comments suggested there was genuine interest in the topics presented in the Safe Dates program.

_______

17. (

The Prevention Coordinator has been very supportive of this school's efforts to implement the Safe Dates curriculum.

_______

One class period provides enough time to implement an entire Safe Dates lesson as prescribed by program developers

_______

The existing violence-prevention policies at this school are very effective.

_______

There is a substantial amount of scientific evidence that indicates Safe Dates is effective in reducing dating violence.

_______

Little effort has been directed to overcoming obstacles that got in the way of implementing the Safe Dates curriculum as prescribed.

_______

The school has the resources to support the implementation of the Safe Dates curriculum BUT ONLY during the course of the study.

_______

Students have been very supportive of this school's efforts to implement the Safe Dates curriculum.

_______

One class period is sufficient to complete the activities recommended for one Safe Dates lesson.

_______

The existing violence-prevention policies at this school are very effective.

_______

The scientific evidence is strong that supports the effectiveness of Safe Dates.

_______

Not enough attention was given to monitoring the early stages of implementing the Safe Dates curriculum at this school.

_______

The school does not have the resources necessary to support the implementation of the Safe Dates curriculum during the course of the study.

_______

There was not enough time to adequately prepare for teaching individual lessons in the Safe Dates curriculum

_______

One class period is sufficient to present the material associated with one Safe Dates lesson

_______

The violence-prevention programs and classes at this school are very effective.

_______

There is convincing scientific evidence which suggests that Safe Dates is effective in reducing dating violence.

_______

This school takes a comprehensive approach to reducing the incidence of violence among our students

_______

INSTRUCTIONS: The Safe Dates curriculum addresses the topic of dating violence and recommends approaches for reducing its occurrence. Whether or not you have had the chance to review the Safe Dates Teacher Manual/Curriculum guide, please carefully read each statement and indicate how much confidence you have that you could accomplish each of these tasks using the 5-point shown below. Enter “0” if you don’t know.

No confidence at all	Very little confidence	Some confidence	A lot of confidence	Complete confidence		Don’t Know
1	2	3	4	5		9

HOW MUCH CONFIDENCE DO YOU HAVE THAT YOU CAN:

	Teach the 9 lessons in the Safe Dates curriculum after reading the teacher manual/curriculum guide	_______
	See to it that the recommended Safe Dates student poster contest is implemented for students in your class.	_______
	See to it that the recommended Safe Dates student play is performed by students in your class.	_______
	Persuade students in your Safe Dates class to actively participate in role-playing exercises.	_______
	Persuade students in your Safe Dates class to work together as a group on Safe Dates group exercises.	_______
	Persuade students in your class to participate in classroom discussions about the topic of dating violence.	_______
	Teach the lessons in the Safe Dates curriculum in strict accordance with the curriculum guide.	_______
	Implement the activities in the Safe Dates curriculum in strict accordance with the curriculum guide.	_______
	Comfortably present information to your students about preventing sexual violence.	_______

Instructions: Using the scale provided below, please indicate the extent to which each of the following describes the implementation of the Safe Dates curriculum at this school. Enter the number that most closely reflects your response in the space provided next to each phrase. Enter “0” if you don’t know.

No Extent/ Not at all	Very Small Extent	Small Extent	Moderate Extent	Considerable Extent	Great Extent	Very Great Extent		Don’t Know
1	2	3	4	5	6	7		9

To what extent…

	…have changes in school leadership hindered the implementation of the Safe Dates curriculum?	_______
	…has teacher turnover hindered the implementation of the Safe Dates curriculum?	_______
	…has lack of clarity about goals and plans hindered the implementation of the Safe Dates curriculum?	_______
	…has lack of clarity about how to implement parts of the Safe Dates curriculum hindered its overall implementation?	_______
	…has lack of resources hindered the implementation of the Safe Dates curriculum?	_______
	…have internal coordination problems hindered the implementation of the Safe Dates curriculum?	_______
	…has interference by outside groups hindered the implementation of the Safe Dates curriculum?	_______
	…has resistance from students hindered the implementation of the Safe Dates curriculum?	_______

Instructions: Using the scale provided below, please indicate the extent to which each of the following describes the implementation of the Safe Dates curriculum at this school. Enter the number that most closely reflects your response in the space provided next to each phrase. Enter “0” if you don’t know.

No Extent/ Not at all	Very Small Extent	Small Extent	Moderate Extent	Considerable Extent	Great Extent	Very Great Extent		Don’t Know
1	2	3	4	5	6	7		0

To what extent…

	…have scheduling problems hindered the implementation of the Safe Dates curriculum?	_______
	…has resistance from key school personnel hindered the implementation of the Safe Dates curriculum?	_______
	…does this school continue to require technical assistance from outside experts in order to implement Safe Dates as prescribed?	_______
	….is this school capable of continuing to implement the Safe Dates curriculum as designed without technical assistance from outside experts?	_______
	…does this school possess the expertise needed to continue to implement Safe Dates program without help from outside experts?	_______

Form Approved

OMB No. 0920-0783

Exp. Date: 06/30/2011

SAFE DATES Evaluation – Lesson 6 Questionnaire

Thank you for assisting us with the Safe Dates evaluation. As you prepare for and teach the Safe Dates curriculum, please keep track of all time that you spend on all Safe Dates-related activities. Please record your time after as soon as possible after each lesson. This will also minimize the effort required to complete this questionnaire.

Please complete and submit this material within two school days of completing this lesson. If you have any questions, please contact Thomas Hylands by phone [1-800-334-8571, x6955] or e-mail [[email protected]].

Date: _____/_____/________

Public Reporting burden of this collection of information is estimated at 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-0783).

A. SCHOOL INFORMATION

1. School name: _______________________________________________________

2. Teacher name: _______________________________________________________

Your participation is important to us. To show our appreciation, after RTI receives your information for all nine Safe Dates lessons, the play, and the poster contest, you will receive an $80 gift card.

B. TIME AND ACTIVITY LOG

In this section, we ask that you record your time spent on each Safe Dates lesson. Instructions and an example are provided below. An activity log for Lesson 6 (“Overcoming Gender Stereotypes”) is on the next screen.

INSTRUCTIONS

• We anticipate that you may teach each Safe Dates lesson to multiple classes. Please record your time separately by class and activity (the rows of the table).

• For activities that are difficult to divide between classes (e.g., preparation, photocopying), record your time under “General Safe Date Activities.”

• Record class-specific activities (e.g., instruction) in the appropriate columns.

• All entries in the grid should sum to the total time you spent related to Safe Dates Lesson 6. There should be no double counting or missed time.

• Do not include or record your time spent completing this questionnaire. We are only interested in the time associated with teaching and preparing for the Safe Dates curriculum.

EXAMPLE

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparation (before class)	60 min	0 min	0 min	0 min	0 min			60 min
Instruction (in class)	0 min	50 min	50 min	50 min	50 min			200 min
Wrap-up (after class)	15 min	5 min	0 min	0 min	0 min			20 min
							Total time	280 min (4 hr 40 m)

TIME AND ACTIVITY LOG

Lesson 6: “Overcoming Gender Stereotypes”

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparation (before class)
Instruction (in class)
Wrap-up (after class)
Other Activities (not included in time reported above)
Other Safe Dates activities (describe below)
							Total time

3. Did you receive assistance from anyone in preparing for or teaching this lesson?
   
   1 _____ Yes 2 _____ No

[If 3=YES, GOTO 3.a]

[If 3=NO, GOTO 4]

a. Please list their job title (e.g., administrative assistant), the activity they assisted with (e.g., photocopying), and estimate the amount of time involved.

__________________________________________________________________

__________________________________________________________________

4. If you recorded time for “Other Safe Dates activities” above (last row), please describe the activities here. This may include attending training classes, meetings related to Safe Dates, supplemental activities, etc.
   
   ______________________________________________________________________
   
   ______________________________________________________________________
   
   ______________________________________________________________________

5. Were any additional materials purchased by the school or by you for this lesson?

1 _____ Yes 2 _____ No

[If 5=YES, GOTO 5.a]

[If 5=NO, GOTO 6]

a. Please estimate the total cost of these materials: ____________________________

b. Please describe briefly: ________________________________________________

___________________________________________________________________

C. SAFE DATES ACTIVITIES

Please complete this section after you have taught Lesson 6 to your students.

Date(s) Lesson 6 taught: _____/_____/_______

	Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Number of students
Were you able to get through the following items in the Lesson 6 outline? Please write “yes” or “no” for each item.
Part 1: Introduction
Part 2: Unfair expectations
Part 3: Images and where they come from
Part 4: Associations
Part 5: Gender stereotypes
Part 6: Stereotyping leads to abuse
Part 7: Conclusion

Instructions: For the following questions, please use the scale provided below to indicate the extent to which you agree with the following statements. Circle the number associated with the response that comes closest to your answer. If you ‘don’t know’ circle “0”; if the statement does not apply to you, circle “9”, not applicable.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

6. The most important parts of this lesson were implemented as prescribed in the Safe Dates curriculum guide.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

7. I modified some of the lesson content in the course of teaching this Safe Dates lesson.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

8. I made modifications in the activities used to teach this Safe Dates lesson.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

9. I taught this Safe Dates lesson exactly as specified in the Safe Dates curriculum guide.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

10. Did you ask students to share any gender stereotypes they’ve run into in dating relationships or in friendships with the opposite sex? (optional activity)

1 _____ Yes 2 _____ No

11. For “Part 2: Unfair Expectations,” did you have students write a story about the last time someone had an unfair expectation of them?

1 _____ Yes 2 _____ No

[If 11=YES, END]

[If 11=NO, GOTO 12]

12. What activity/method did you do/use instead?

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Form Approved

OMB No. 0920-0783

Exp. Date: 06/30/2011

SAFE DATES Evaluation – Lesson 7 Questionnaire

Thank you for assisting us with the Safe Dates evaluation. As you prepare for and teach the Safe Dates curriculum, please keep track of all time that you spend on all Safe Dates-related activities. Please record your time after as soon as possible after each lesson. This will also minimize the effort required to complete this questionnaire.

Please complete and submit this material within two school days of completing this lesson. If you have any questions, please contact Thomas Hylands by phone [1-800-334-8571, x6955] or e-mail [[email protected]].

Date: _____/_____/________

Public Reporting burden of this collection of information is estimated at 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-0783).

A. SCHOOL INFORMATION

1. School name: _______________________________________________________

2. Teacher name: _______________________________________________________

Your participation is important to us. To show our appreciation, after RTI receives your information for all nine Safe Dates lessons, the play, and the poster contest, you will receive an $80 gift card.

B. TIME AND ACTIVITY LOG

In this section, we ask that you record your time spent on each Safe Dates lesson. Instructions and an example are provided below. An activity log for Lesson 7 (“Equal Power Through Communication”) is on the next screen.

INSTRUCTIONS

• We anticipate that you may teach each Safe Dates lesson to multiple classes. Please record your time separately by class and activity (the rows of the table).

• For activities that are difficult to divide between classes (e.g., preparation, photocopying), record your time under “General Safe Date Activities.”

• Record class-specific activities (e.g., instruction) in the appropriate columns.

• All entries in the grid should sum to the total time you spent related to Safe Dates Lesson 7. There should be no double counting or missed time.

• Do not include or record your time spent completing this questionnaire. We are only interested in the time associated with teaching and preparing for the Safe Dates curriculum.

EXAMPLE

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparation (before class)	60 min	0 min	0 min	0 min	0 min			60 min
Instruction (in class)	0 min	50 min	50 min	50 min	50 min			200 min
Wrap-up (after class)	15 min	5 min	0 min	0 min	0 min			20 min
							Total time	280 min (4 hr 40 m)

TIME AND ACTIVITY LOG

Lesson 7: “Equal Power Through Communication”

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparation (before class)
Instruction (in class)
Wrap-up (after class)
Other Activities (not included in time reported above)
Other Safe Dates activities (describe below)
							Total time

3. Did you receive assistance from anyone in preparing for or teaching this lesson?
   
   1 _____ Yes 2 _____ No

[If 3=YES, GOTO 3.a]

[If 3=NO, GOTO 4]

a. Please list their job title (e.g., administrative assistant), the activity they assisted with (e.g., photocopying), and estimate the amount of time involved.

__________________________________________________________________

__________________________________________________________________

4. If you recorded time for “Other Safe Dates activities” above (last row), please describe the activities here. This may include attending training classes, meetings related to Safe Dates, supplemental activities, etc.
   
   ______________________________________________________________________
   
   ______________________________________________________________________
   
   ______________________________________________________________________

5. Were any additional materials purchased by the school or by you for this lesson?

1 _____ Yes 2 _____ No

[If 5=YES, GOTO 5.a]

[If 5=NO, GOTO 6]

a. Please estimate the total cost of these materials: ____________________________

b. Please describe briefly: ________________________________________________

___________________________________________________________________

C. SAFE DATES ACTIVITIES

Please complete this section after you have taught Lesson 7 to your students.

Date(s) Lesson 7 taught: _____/_____/_______

	Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Number of students
Were you able to get through the following items in the Lesson 7 outline? Please write “yes” or “no” for each item.
Part 1: The eight skills of effective communication
Part 2: Identifying communication skills
Part 3: Role-playing communication skills
Part 4: What if it doesn’t work?
Part 5: Conclusion

Instructions: For the following questions, please use the scale provided below to indicate the extent to which you agree with the following statements. Circle the number associated with the response that comes closest to your answer. If you ‘don’t know’ circle “0”; if the statement does not apply to you, circle “9”, not applicable.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

6. The most important parts of this lesson were implemented as prescribed in the Safe Dates curriculum guide.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

7. I modified some of the lesson content in the course of teaching this Safe Dates lesson.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

8. I made modifications in the activities used to teach this Safe Dates lesson.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

9. I taught this Safe Dates lesson exactly as specified in the Safe Dates curriculum guide.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

10. Did you post the Eight Basic Skills for Building Equal Power through Communication handout in your classroom or around your school? (optional activity)

1 _____ Yes 2 _____ No

Form Approved

OMB No. 0920-0783

Exp. Date: 06/30/2011

SAFE DATES Evaluation – Lesson 8 Questionnaire

Thank you for assisting us with the Safe Dates evaluation. As you prepare for and teach the Safe Dates curriculum, please keep track of all time that you spend on all Safe Dates-related activities. Please record your time after as soon as possible after each lesson. This will also minimize the effort required to complete this questionnaire.

Please complete and submit this material within two school days of completing this lesson. If you have any questions, please contact Thomas Hylands by phone [1-800-334-8571, x6955] or e-mail [[email protected]].

Date: _____/_____/________

Public Reporting burden of this collection of information is estimated at 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-0783).

A. SCHOOL INFORMATION

1. School name: _______________________________________________________

2. Teacher name: _______________________________________________________

Your participation is important to us. To show our appreciation, after RTI receives your information for all nine Safe Dates lessons, the play, and the poster contest, you will receive an $80 gift card.

B. TIME AND ACTIVITY LOG

In this section, we ask that you record your time spent on each Safe Dates lesson. Instructions and an example are provided below. An activity log for Lesson 8 (“How We Feel, How We Deal”) is on the next screen.

INSTRUCTIONS

• We anticipate that you may teach each Safe Dates lesson to multiple classes. Please record your time separately by class and activity (the rows of the table).

• For activities that are difficult to divide between classes (e.g., preparation, photocopying), record your time under “General Safe Date Activities.”

• Record class-specific activities (e.g., instruction) in the appropriate columns.

• All entries in the grid should sum to the total time you spent related to Safe Dates Lesson 8. There should be no double counting or missed time.

• Do not include or record your time spent completing this questionnaire. We are only interested in the time associated with teaching and preparing for the Safe Dates curriculum.

EXAMPLE

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparation (before class)	60 min	0 min	0 min	0 min	0 min			60 min
Instruction (in class)	0 min	50 min	50 min	50 min	50 min			200 min
Wrap-up (after class)	15 min	5 min	0 min	0 min	0 min			20 min
							Total time	280 min (4 hr 40 m)

TIME AND ACTIVITY LOG

Lesson 8: “How We Feel, How We Deal”

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparation (before class)
Instruction (in class)
Wrap-up (after class)
Other Activities (not included in time reported above)
Other Safe Dates activities (describe below)
							Total time

3. Did you receive assistance from anyone in preparing for or teaching this lesson?
   
   1 _____ Yes 2 _____ No

[If 3=YES, GOTO 3.a]

[If 3=NO, GOTO 4]

a. Please list their job title (e.g., administrative assistant), the activity they assisted with (e.g., photocopying), and estimate the amount of time involved.

__________________________________________________________________

__________________________________________________________________

4. If you recorded time for “Other Safe Dates activities” above (last row), please describe the activities here. This may include attending training classes, meetings related to Safe Dates, supplemental activities, etc.
   
   ______________________________________________________________________
   
   ______________________________________________________________________
   
   ______________________________________________________________________

5. Were any additional materials purchased by the school or by you for this lesson?

1 _____ Yes 2 _____ No

[If 5=YES, GOTO 5.a]

[If 5=NO, GOTO 6]

a. Please estimate the total cost of these materials: ____________________________

b. Please describe briefly: ________________________________________________

___________________________________________________________________

C. SAFE DATES ACTIVITIES

Please complete this section after you have taught Lesson 8 to your students.

Date(s) Lesson 8 taught: _____/_____/_______

	Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Number of students
Were you able to get through the following items in the Lesson 8 outline? Please write “yes” or “no” for each item.
Part 1: Extending your feeling vocabulary
Part 2: Hot buttons
Part 3: Knowing when you’re angry
Part 4: Defusing anger
Part 5: Dealing with anger
Part 6: Conclusion

Instructions: For the following questions, please use the scale provided below to indicate the extent to which you agree with the following statements. Circle the number associated with the response that comes closest to your answer. If you ‘don’t know’ circle “0”; if the statement does not apply to you, circle “9”, not applicable.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

6. The most important parts of this lesson were implemented as prescribed in the Safe Dates curriculum guide.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

7. I modified some of the lesson content in the course of teaching this Safe Dates lesson.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

8. I made modifications in the activities used to teach this Safe Dates lesson.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

9. I taught this Safe Dates lesson exactly as specified in the Safe Dates curriculum guide.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

10. For “Part 5: Dealing with Anger,” did you allow a pair of students to share their solutions? (optional activity)

1 _____ Yes 2 _____ No

11. For “Part 6: Conclusion,” did you give students Handout 25: Feelings Diary to complete as homework?

1 _____ Yes 2 _____ No

[If 11=YES, END]

[If 11=NO, GOTO 12]

12. Briefly describe any other homework you may have given instead of Handout 25.

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Form Approved

OMB No. 0920-0783

Exp. Date: 06/30/2011

SAFE DATES Evaluation – Lesson 9 Questionnaire

Thank you for assisting us with the Safe Dates evaluation. As you prepare for and teach the Safe Dates curriculum, please keep track of all time that you spend on all Safe Dates-related activities. Please record your time after as soon as possible after each lesson. This will also minimize the effort required to complete this questionnaire.

Please complete and submit this material within two school days of completing this lesson. If you have any questions, please contact Thomas Hylands by phone [1-800-334-8571, x6955] or e-mail [[email protected]].

Date: _____/_____/________

Public Reporting burden of this collection of information is estimated at 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-0783).

Your participation is important to us. To show our appreciation, after RTI receives your information for all nine Safe Dates lessons, the play, and the poster contest, you will receive an $80 gift card.

A. TIME AND ACTIVITY LOG

In this section, we ask that you record your time spent on each Safe Dates lesson. Instructions and an example are provided below. An activity log for Lesson 9 (“Preventing Sexual Assault”) is on the next screen.

INSTRUCTIONS

• We anticipate that you may teach each Safe Dates lesson to multiple classes. Please record your time separately by class and activity (the rows of the table).

• For activities that are difficult to divide between classes (e.g., preparation, photocopying), record your time under “General Safe Date Activities.”

• Record class-specific activities (e.g., instruction) in the appropriate columns.

• All entries in the grid should sum to the total time you spent related to Safe Dates Lesson 9. There should be no double counting or missed time.

• Do not include or record your time spent completing this questionnaire. We are only interested in the time associated with teaching and preparing for the Safe Dates curriculum.

EXAMPLE

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparation (before class)	60 min	0 min	0 min	0 min	0 min			60 min
Instruction (in class)	0 min	50 min	50 min	50 min	50 min			200 min
Wrap-up (after class)	15 min	5 min	0 min	0 min	0 min			20 min
Optional Activities (not included in time reported above)
Administer post-test (if time not included above)	20min	15 min	15 min	15 min	15 min			80 min
Create and photocopy Poster Contest Fliers	30min	0min	0min	0min	0min			30 min
							Total time	390 min (6 hr 30 m)

TIME AND ACTIVITY LOG

Lesson 9: “Preventing Sexual Assault”

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparation (before class)
Instruction (in class)
Wrap-up (after class)
Optional Activities (not included in time reported above)
Administer post- test (if time not included above)
Create and photocopy Poster Contest Fliers
Other Activities (not included in time reported above)
Other Safe Dates activities (describe below)
							Total time

1. Did you receive assistance from anyone in preparing for or teaching this lesson?

1 _____ Yes 2 _____ No

[If 1=YES, GOTO 2]

[If 1=NO, GOTO 3]

2. Please list their job title (e.g., administrative assistant), the activity they assisted with (e.g., photocopying), and estimate the amount of time involved.

__________________________________________________________________
__________________________________________________________________

3. If you recorded time for “Other Safe Dates activities” above (last row), please describe the activities here. This may include attending training classes, meetings related to Safe Dates, supplemental activities, etc.
   
   ______________________________________________________________________
   ______________________________________________________________________
   
   

3. Were any additional materials purchased by the school or by you for this lesson?

1 _____ Yes 2 _____ No

[If 4=YES, GOTO 4.a]

[If 4=NO, GOTO 5]

4a. Please estimate the total cost of these materials: _______________________

4b. Please describe briefly: ___________________________________________
___________________________________________________________________

B. SAFE DATES ACTIVITIES

Please complete this section after you have taught Lesson 9 to your students.

Date(s) Lesson 9 taught: _____/_____/_______

	Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Number of students
Were you able to get through the following items in the Lesson 9 outline? Please write “yes” or “no” for each item.
Part 1: Understanding sexual assault
Part 2: Confronting victim blaming
Part 3: Interpreting cues
Part 4: Precautions
Part 5: Reviewing the Safe Dates program
Optional post-test

Instructions: For the following questions, please use the scale provided below to indicate the extent to which you agree with the following statements. Circle the number associated with the response that comes closest to your answer. If you ‘don’t know” circle “0”; if the statement does not apply to you, circle “9”, not applicable.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

3. The most important parts of this lesson were implemented as prescribed in the Safe Dates curriculum guide.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

3. I modified some of the lesson content in the course of teaching this Safe Dates lesson.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

3. I made modifications in the activities used to teach this Safe Dates lesson.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

3. I taught this Safe Dates lesson exactly as specified in the Safe Dates curriculum guide.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

3. For “Part 2: Confronting Victim Blaming,” did you ask students the optional question concerning the role alcohol may have played in the date rape situation?

1 _____ Yes 2 _____ No

3. Did you have students compare their answers from the post-test to their pre-test to see changes in their knowledge and attitudes?

1 _____ Yes 2 _____ No

3. Did you allow students to keep their journals and encourage them to review them regularly? (optional activity)

1 _____ Yes 2 _____ No

We are seeking your first impressions and reactions.

Please provide responses based on what you know or what you think. Feel free to use the ‘don’t know’ option as needed. There are no “right” or “wrong” answers.

We recommend that you work quickly without puzzling or worrying about individual questions. We are aware that some questions may appear to be repetitive but it is necessary to ask a variety of questions to obtain reliable and accurate information about the topics addressed in the questionnaire.

Privacy:

All answers you provide will be kept private. Findings will be summarized in aggregated form to protect the identity of participating individuals and schools.

Background Information: Please provide the following information so that we a) can match your answers to this survey with those on follow-up surveys b) describe study participants, and c) group responses according to title, school, etc. The information you provide will be kept private.

12. Your title: _______________________	13. Duration of a health class period: ______ minutes.

	14.	Which of the following options best describes how the Safe Dates (SD) Program is being incorporated into your school's broader health or prevention curriculum? ____ Independent course in the health or prevention curriculum ____ Discrete module within a course in the health or prevention curriculum ____ Safe Dates lessons are being interspersed among other topics the curriculum ____ Other (please explain: ______________________________________________)
	15. 16.	The Safe Dates curriculum is designed to be taught in the form of nine, 50-minute lessons. Please indicate the actual kickoff date and a likely completion date for teaching the 9- session Safe Dates curriculum. The actual kick-off date for the Safe Dates Curriculum was (mm/dd/yy): _______________ The estimated completion date for the Safe Dates Curriculum is (mm/dd/yy): ____________
	17.	Thinking back to the first five lessons in the Safe Dates curriculum, for how many of those lessons did you follow the curriculum guide to the letter? ____ None of the first five Safe Dates lessons ____ 1 of the first 5 ____ 2 of the first 5 ____ 3 of the first 5 ____ 4 of the first 5 ____ All five of the first 5 Safe Dates lessons

Instructions: Using the scale provided below, please indicate the extent to which you agree with each of the following statements. Enter the number that most closely reflects your response in the space provided next to each phrase. Enter “0” if you don’t know or “9” if the question does not apply to you or your school.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

The Safe Dates curriculum must be implemented in a precise and prescribed manner in order to be effective.

_______

In my view, formal training is needed in order for teachers to do a good job implementing the Safe Dates curriculum.

_______

The Safe Dates curriculum is complicated to implement correctly.

_______

I have implemented the Safe Dates curriculum exactly as has been prescribed by its developers.

_______

I followed the curriculum guide to the letter in the process of teaching the Safe Dates program.

_______

The only reason that I am teaching the Safe Dates curriculum is because I have to.

_______

I added classroom activities to one or more Safe Dates lesson.

_______

The district office has been very supportive of this school's efforts to implement the Safe Dates curriculum.

_______

It is not clear who is leading this school's efforts to implement the Safe Dates curriculum.

_______

If needed, teachers have access to experts who know how to implement the Safe Dates curriculum.

_______

Clear and specific goals have been established pertaining to the implementation of the Safe Dates curriculum during the course of the study.

_______

School administrators adequately address the concerns of teachers charged with implementing the Safe Dates curriculum.

_______

This school has the resources necessary to support the ongoing implementation of Safe Dates.

_______

Teachers involved in implementing the Safe Dates curriculum get recognition from their supervisors.

_______

The administration monitors how things are going with the implementation of the Safe Dates curriculum.

_______

Teachers are not speaking up although they harbor serious doubts about the effectiveness of Safe Dates.

_______

Overall, students seem to like the Safe Dates curriculum.

_______

Instructions: Using the scale provided below, please indicate the extent to which you agree with each of the following statements. Enter the number that most closely reflects your response in the space provided next to each phrase. Enter “0” if you don’t know or “9” if the question does not apply to you or your school.

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

Most students seemed interested in the material presented in the Safe Dates program.

_______

Adaptations can be made in how the Safe Dates curriculum is implemented without jeopardizing its effectiveness.

_______

The curriculum guide is sufficient to prepare the average teacher to do a good job implementing the Safe Dates curriculum.

_______

It is easy to prepare teachers to implement the Safe Dates curriculum as recommended by experts.

_______

I have made modifications in the Safe Dates curriculum while teaching one or more of the first five lessons.

_______

I rarely followed the curriculum guide in the process of teaching Safe Dates lessons.

_______

I am teaching the Safe Dates curriculum because I want to.

_______

I added material to one or more of the first five Safe Dates lessons.

_______

The school board has been very supportive of this school's efforts to implement the Safe Dates (prevention) curriculum.

_______

There was not enough time to adequately plan for the implementation of the Safe Dates curriculum at this school.

_______

Training is available to any teacher who needs guidance in order to implement Safe Dates as prescribed by experts.

_______

The school administration has clearly communicated its expectations pertaining to the implementation of the Safe Dates curriculum during the course of the study.

_______

School administrators insure that everything necessary for the implementation of Safe Dates is made available to teachers.

_______

The school has the manpower necessary to support the ongoing implementation of Safe Dates.

_______

Teachers are given positive feedback for contributing to the implementation of the Safe Dates program.

_______

The administration holds meetings with teachers to review how the implementation of Safe Dates is going.

_______

Teachers are encouraged to speak openly about the strengths and weaknesses of the Safe Dates curriculum from the Prevention Coordinator and/or teachers.

_______

The Prevention Coordinator seems to like the Safe Dates curriculum.

_______

Overall, students seemed engaged in Safe Dates classroom activities.

_______

Some components of the Safe Dates curriculum have to be implemented as prescribed but others do not.

_______

In my view, the average teacher is likely to need follow-up training or coaching in order to do a good job implementing the Safe Dates curriculum.

_______

There are one or more reasons why it’s difficult for teachers to implement the Safe Dates curriculum at this school.

_______

I have implemented the most important elements of the Safe Dates curriculum as it has been prescribed by program developers.

_______

Instructions: Using the scale provided below, please indicate the extent to which you agree with each of the following statements. Enter the number that most closely reflects your response in the space provided next to each phrase. Enter “0” if you don’t know or “9” if the question does not apply to you or your school

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

I taught the material exactly as specified in the Safe Dates curriculum guide.

_______

I made modifications in the course of teaching the Safe Dates curriculum.

_______

Parents generally have been very supportive of this school's efforts to implement the Safe Dates curriculum.

_______

The implementation of the Safe Dates curriculum has not been well coordinated at this school.

_______

If questions arise about implementing the Safe Dates program, teachers have ready access to needed information.

_______

Teachers who are responsible for implementing the Safe Dates curriculum have a clear understanding of their roles and responsibilities.

_______

Teachers responsible for implementing Safe Dates believe they are given the tools and resources they need to do so effectively.

_______

We do not have the resources necessary to implement the Safe Dates program on a long-term basis.

_______

Teachers responsible for implementing the Safe Dates program know their efforts are appreciated by this school.

_______

The administration gets regular progress reports about the implementation of the Safe Dates curriculum.

_______

Often teachers feel pressured not to “rock the boat” by speaking their minds about the pros and cons of the Safe Dates curriculum.

_______

School administrators appear to like the Safe Dates curriculum.

_______

Students frequently asked questions during Safe Dates classes.

_______

Teaching Safe Dates exactly as it was developed by experts is critical to getting expected results.

_______

After reviewing the curriculum guide, the average teacher will be well-equipped to do a good job implementing the Safe Dates curriculum.

_______

It is easy to implement the Safe Dates curriculum correctly on a consistent basis.

_______

The way I am implementing Safe Dates departs significantly from what is prescribed by its developers.

_______

I made modifications in the activities used to teach the Safe Dates curriculum.

_______

The School principal has been very supportive of this school's efforts to implement the Safe Dates curriculum.

_______

The individual in charge of leading the effort to implement the Safes Dates curriculum lacked some important skills.

_______

Technical assistance is available to teachers who are responsible for teaching Safe Dates.

_______

School administrators do a good job removing barriers that interfere with teaching the Safe Dates curriculum exactly as prescribed.

_______

This school has the resources necessary to support the initial implementation of Safe Dates.

_______

Top administrators provide encouragement to teachers involved in implementing the Safe Dates program.

_______

The administration pays close attention to the progress being made related to implementing the Safe Dates program.

_______

Instructions: Using the scale provided below, please indicate the extent to which you agree with each of the following statements. Enter the number that most closely reflects your response in the space provided next to each phrase. Enter “0” if you don’t know or “9” if the question does not apply to you or your school

Strongly Disagree	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree	Agree	Strongly Agree		Don’t Know	Not Applicable
1	2	3	4	5	6	7		0	9

Overall, parents seem to like the Safe Dates curriculum.

_______

Student comments suggested there was genuine interest in the topics presented in the Safe Dates program.

_______

The Prevention Coordinator has been very supportive of this school's efforts to implement the Safe Dates curriculum.

_______

One class period provides enough time to implement an entire Safe Dates lesson as prescribed by program developers

_______

The existing violence-prevention policies at this school are very effective.

_______

There is a substantial amount of scientific evidence that indicates Safe Dates is effective in reducing dating violence.

_______

Little effort has been directed to overcoming obstacles that got in the way of implementing the Safe Dates curriculum as prescribed.

_______

The school has the resources to support the implementation of the Safe Dates curriculum BUT ONLY during the course of the study.

_______

Students have been very supportive of this school's efforts to implement the Safe Dates curriculum.

_______

One class period is sufficient to complete the activities recommended for one Safe Dates lesson.

_______

The existing violence-prevention policies at this school are very effective.

_______

The scientific evidence is strong that supports the effectiveness of Safe Dates.

_______

Not enough attention was given to monitoring the early stages of implementing the Safe Dates curriculum at this school.

_______

The school does not have the resources necessary to support the implementation of the Safe Dates curriculum during the course of the study.

_______

There was not enough time to adequately prepare for teaching individual lessons in the Safe Dates curriculum

_______

One class period is sufficient to present the material associated with one Safe Dates lesson

_______

The violence-prevention programs and classes at this school are very effective.

_______

There is convincing scientific evidence which suggests that Safe Dates is effective in reducing dating violence.

_______

This school takes a comprehensive approach to reducing the incidence of violence among our students

_______

INSTRUCTIONS: The Safe Dates curriculum addresses the topic of dating violence and recommends approaches for reducing its occurrence. Whether or not you have had the chance to review the Safe Dates Teacher Manual/Curriculum guide, please carefully read each statement and indicate how much confidence you have that you could accomplish each of these tasks using the 5-point shown below. Enter “0” if you don’t know.

No confidence at all	Very little confidence	Some confidence	A lot of confidence	Complete confidence		Don’t Know
1	2	3	4	5		0

HOW MUCH CONFIDENCE DO YOU HAVE THAT YOU CAN:

	Teach the 9 lessons in the Safe Dates curriculum after reading the teacher manual/curriculum guide	_______
	See to it that the recommended Safe Dates student poster contest is implemented for students in your class.	_______
	See to it that the recommended Safe Dates student play is performed by students in your class.	_______
	Persuade students in your Safe Dates class to actively participate in role-playing exercises.	_______
	Persuade students in your Safe Dates class to work together as a group on Safe Dates group exercises.	_______
	Persuade students in your class to participate in classroom discussions about the topic of dating violence.	_______
	Teach the lessons in the Safe Dates curriculum in strict accordance with the curriculum guide.	_______
	Implement the activities in the Safe Dates curriculum in strict accordance with the curriculum guide.	_______
	Comfortably present information to your students about preventing sexual violence.	_______

Instructions: Using the scale provided below, please indicate the extent to which each of the following describes the implementation of the Safe Dates curriculum at this school. Enter the number that most closely reflects your response in the space provided next to each phrase. Enter “0” if you don’t know.

No Extent/ Not at all	Very Small Extent	Small Extent	Moderate Extent	Considerable Extent	Great Extent	Very Great Extent		Don’t Know
1	2	3	4	5	6	7		0

To what extent…

	…have changes in school leadership hindered the implementation of the Safe Dates curriculum?	_______
	…has teacher turnover hindered the implementation of the Safe Dates curriculum?	_______
	…has lack of clarity about goals and plans hindered the implementation of the Safe Dates curriculum?	_______
	…has lack of clarity about how to implement parts of the Safe Dates curriculum hindered its overall implementation?	_______
	…has lack of resources hindered the implementation of the Safe Dates curriculum?	_______
	…have internal coordination problems hindered the implementation of the Safe Dates curriculum?	_______
	…has interference by outside groups hindered the implementation of the Safe Dates curriculum?	_______
	…has resistance from students hindered the implementation of the Safe Dates curriculum?	_______

Instructions: Using the scale provided below, please indicate the extent to which each of the following describes the implementation of the Safe Dates curriculum at this school. Enter the number that most closely reflects your response in the space provided next to each phrase. Enter “0” if you don’t know.

No Extent/ Not at all	Very Small Extent	Small Extent	Moderate Extent	Considerable Extent	Great Extent	Very Great Extent		Don’t Know
1	2	3	4	5	6	7		0

To what extent…

	…have scheduling problems hindered the implementation of the Safe Dates curriculum?	_______
	…has resistance from key school personnel hindered the implementation of the Safe Dates curriculum?	_______
	…does this school continue to require technical assistance from outside experts in order to implement Safe Dates as prescribed?	_______
	….is this school capable of continuing to implement the Safe Dates curriculum as designed without technical assistance from outside experts?	_______
	…does this school possess the expertise needed to continue to implement Safe Dates program without help from outside experts?	_______

Form Approved

OMB No. 0920-0783

Exp. Date: 06/30/2011

SAFE DATES Evaluation – Poster Contest

Thank you for assisting us with the Safe Dates evaluation. This questionnaire asks about time and materials specifically related to the Safe Dates poster contest.

Please submit this information within two school days of holding the poster contest. If you have any questions, please contact Thomas Hylands by phone [1-800-334-8571, x6955] or e-mail [[email protected]].

Date: _____/_____/________

Public Reporting burden of this collection of information is estimated at 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-0783).

A. COMPLETION

1. School name: _______________________________________________________

2. Teacher name: _______________________________________________________

3. Did you conduct the Safe Dates poster contest?

1 _____ Yes

2 _____ No

[IF 3=Yes GOTO next screen]

[IF 3=No TERMINATE]

Your participation is important to us. To show our appreciation, after RTI receives information for all nine Safe Dates lessons, the play, and the poster contest, you will receive an $80 gift card.

B. TIME AND ACTIVITY LOG

In this section, we ask that you record your time spent specifically on the Safe Dates poster contest. Instructions and an example are provided below. The activity log that you should complete is on the next screen.

INSTRUCTIONS

• Only report time that has not been reported on the Lessons 1-9 forms.

• We anticipate that you may conduct the Safe Dates poster contest multiple times with different classes. Please record your time separately by class and activity (the rows of the table) as appropriate.

• For activities that are difficult to divide between classes (e.g., preparation, photocopying), record your time under “General Safe Dates Activities.”

• Record class-specific activities (e.g., judging of posters) in the appropriate columns.

• All entries in the grid should sum to the total time you spent related to the Safe Dates poster contest. There should be no double counting.

• Do not include or record your time spent completing this questionnaire. We are only interested in the time associated with activities of the Safe Dates poster contest.

EXAMPLE

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparing for poster contest	60 min	0 min	0 min	0 min	0 min			60 min
Conducting poster contest	0 min	30 min	30 min	30 min	30 min			120 min
Wrap-up of poster contest	20 min	0 min	0 min	0 min	0 min			20 min
Other poster contest activities (if time not included above)	0 min	0 min	0 min	0 min	0 min			0 min
							Total time	200 min (3 hr 20 m)

TIME AND ACTIVITY LOG

Safe Dates Poster Contest

Date(s) Poster Contest held: _________________

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparing for poster contest
Conducting poster contest
Wrap-up of poster contest
Other poster contest activities (if time not included above)
							Total time

4. If you recorded time for “Other poster contest activities” above (last row), please describe the activities here. This may include time spent obtaining art supplies, talking to an art teacher, etc.
   
   ______________________________________________________________________
   
   ______________________________________________________________________
   
   ______________________________________________________________________
   
   ______________________________________________________________________
   
   ______________________________________________________________________
   
   
   

5. Were prizes or any additional materials purchased by the school or by you for the contest? (For example, gift cards for prizes, poster board and markers, etc.)

1 _____ Yes 2 _____ No

[IF 5=Yes GOTO 5a]

[IF 5=No GOTO 6]

2. Please estimate the total cost of these materials: ____________________________
   
   ___________________________________________________________________
   
   ___________________________________________________________________
   
   ___________________________________________________________________
   
   ___________________________________________________________________

6. Did you receive assistance from anyone in conducting the poster contest? (For example, an art teacher, another teacher, or an administrative assistant.)
   
   1 _____ Yes 2 _____ No
   
   

[IF 6=Yes GOTO 6a]

[IF 6=No GOTO 7]

1. Please list their job title, the activity they assisted with (e.g., photocopying poster contest fliers), and estimate the total amount of time that they contributed.
   
   __________________________________________________________________
   
   __________________________________________________________________
   
   __________________________________________________________________
   
   __________________________________________________________________
   
   __________________________________________________________________
   
   __________________________________________________________________
   
   __________________________________________________________________
   
   __________________________________________________________________
   
   __________________________________________________________________
   
   __________________________________________________________________

Form Approved

OMB No. 0920-0783

Exp. Date: 06/30/2011

SAFE DATES Evaluation –

“There’s No Excuse for Dating Abuse” Play

Thank you for assisting us with the Safe Dates evaluation. This questionnaire asks about time and materials specifically related to the Safe Dates play.

Please submit this questionnaire within two school days of performing the play. If you have any questions, please contact Thomas Hylands by phone [1-800-334-8571, x6955] or e-mail [[email protected]].

Date: _____/_____/________

Public Reporting burden of this collection of information is estimated at 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-0783).

A. COMPLETION

1. School name: _______________________________________________________

2. Teacher name: _______________________________________________________

3. Did you conduct the Safe Dates play, “There’s No Excuse for Dating Abuse”?

1 _____ Yes

2 _____ No

[IF 3=Yes GOTO next screen]

[IF 3=No TERMINATE]

Your participation is important to us. To show our appreciation, after RTI receives information for all nine Safe Dates lessons, the play, and the poster contest, you will receive an 80 gift card.

B. TIME AND ACTIVITY LOG

In this section, we ask that you record your time spent specifically on the Safe Dates play, “There’s No Excuse for Dating Abuse.” Instructions and an example are provided below. The activity log that you should complete is on the following screens.

INSTRUCTIONS

• Only report time that has not been reported on the Lessons 1-9 forms.

• We anticipate that you may conduct the Safe Dates play multiple times with different classes. Please record your time separately by class and activity (the rows of the table) as appropriate.

• For activities that are difficult to divide between classes (e.g., preparation, photocopying), record your time under “General Safe Dates Activities.”

• Record class-specific activities (e.g., rehearsals) in the appropriate columns.

• All entries in the grid should sum to the total time you spent related to the Safe Dates play. There should be no double counting.

• Do not include or record your time spent completing this questionnaire. We are only interested in the time associated with activities of the Safe Dates play.

EXAMPLE

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparing for the play (rehearsals, etc.)	30 min	40 min	40 min	40 min	40 min			190 min
Conducting the play (performance, post-discussion)	0 min	40 min	40 min	40 min	40 min			160 min
Wrap-up of the play (any activities after the performance)	0 min	5 min	5 min	5 min	5 min			20 min
Other play activities (if time not included above)	0 min	0 min	0 min	0 min	0 min			0 min
							Total time	370 min (6 hr 10 m)

TIME AND ACTIVITY LOG

Safe Dates Play

4. Date(s) Play performed: _____/_____/______

	General Safe Dates Activities	Class-Specific Activities						Total time
		Class 1	Class 2	Class 3	Class 4	Class 5	Class 6
Preparing for the play (rehearsals, etc.)
Conducting the play (performance, post-discussion)
Wrap-up of the play (any activities after the performance)
Other play activities (if not included above)
							Total time

5. If you recorded time for “Other play activities” above (last row), please describe the activities here. This may include time spent obtaining props, meetings related to the play performance, gathering local statistics, etc. ______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

6. Did you receive assistance from anyone in conducting the play (for example, a drama teacher, another teacher, or an administrative assistant)?

1 _____ Yes 2 _____ No

[IF 6=Yes GOTO 6.a]

[IF 6=No GOTO 7]

6.

1. Please list their job title, the activity they assisted with (e.g., coordinating with drama students), and estimate the total amount of time that they contributed.
   
   __________________________________________________________________
   
   __________________________________________________________________
   
   __________________________________________________________________
   
   __________________________________________________________________

7. Were any materials purchased by you or the school in order for you to perform the play (e.g., props, costumes, posterboard, etc)?

1 _____ Yes 2 _____ No

[IF 7=Yes GOTO 7a]

[IF 7=NO GOTO 8]

a. If yes, please estimate the total cost of these materials: _______________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

8. Who performed the Safe Dates play?

1 _____ My Safe Dates students

2 _____ My school’s drama class. (please make sure you completed Question 6 above.)

3 _____ Others. (Please specify):___________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

9. What type of audience was the play performed in front of?

1 _____ My Safe Dates class(es)

2 _____ A broader audience of students, including others not in my Safe Dates class(es)

3 _____ Other (Please specify):_____________________________________________

__________________________________________________